Chapter 21: The Health Record

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Last updated 10:11 PM on 7/18/26
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11 Terms

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What is the purpose of the health record?
Documents patient care, supports continuity, billing, legal protection, and quality improvement.
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What is subjective information?
Information reported by the patient, such as symptoms.
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What is objective information?
Measurable/observable data, such as vital signs or exam findings.
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What does SOAP stand for?
Subjective, Objective, Assessment, Plan.
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What is an EMR?
Electronic medical record typically used within one organization.
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What is an EHR?
Electronic health record designed for broader sharing across authorized healthcare organizations.
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What is a chief complaint?
Patient's main reason for the visit, usually in the patient's own words.
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What is the rule for documentation timing?
Document as soon as possible after care or activity.
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What should be documented after a procedure?
Date/time, procedure, patient response, results/observations, education, and MA initials/signature per policy.
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What is the correct way to document a late entry?
Label as a late entry, include the current date/time, event date/time, objective information, and signature.
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What should the MA avoid in documentation?
Personal opinions, blame, vague wording, and unapproved abbreviations.